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' ��CITY OF DIAMOND HA& �� EXPIRED •- R — DEPARTMENT OF COMMUIJITY d�DE LOPMENT SERVICES 21660 E.Copley Drivc 5uitc 190 0 C T 0 3 1000 PRESS (909)860-3145 Fax(909)861-3117 ��A��� BUII.DING PERMIT APPLICA'TION FIRMLY y JOBSITE APPLICATION n PERMIT P/C o ADDRESS � DATE d'I� NUMBER�i1 � ISSUE TYPE OCC APN--�-�- L T 7RACT DATE CONST. GROUP � OWNER W AD SS ZONING SETBACKS CITY ZIP TEL. FRONT RW ❑ APPtiCANT TEL. REAR L] SIDFJSIDE STREET RW O CONTRACT Y• O S�DE ❑ g ADD SS PROPOSED USE C ZI U TEL. e ARCH/ENG/ � DESIGNER NO.DWEL. NO. NO. ADDRESS UNITS STORIES BEDROOMS CITY ZIP TEL � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION OONMEFi-BUILDER DECLARATION 5FR/A��/REM p 1 NEREBY AFFitlA UNOER iENALTY OF iEiWRY TIAT 1 AM EXEMP7 FAOA1 THE CONTRACTONS Lb GerBgelCBIpD11 0 CENSEUWFCMTMEFOLL0INMJGREASON�SEC.70.9t.6BUfNE59ANDPROFE5510N3CO0E:ANYCfT/OR (n C� QOIMiYWHIpiREOUTAESAPEAMRTOOqV6TRVCT,ALTERNiVF10VE.OENDU6FLORREPNRANY87RUG W patiolDeck �� TUpE,►RIOR 70 ITS 189UANCE,11L50 REOUINES TIIE APPLICMIT FOR SUCM PEIIMIT TO FILE A SIONEO tTATEMENT TU1T ME OF SME IS UCENSED OURSUANT TO TNE i1qN510N8 OF TNE CONTRACTOFl9 ll• CENSE LAW(CIUPTER 9(COMMENCINO WRH iCLRIDN 7000)OF DIVISION 7 OF THE BV91NES9 AND PRO� LL' POOUSp9 fF5810N5OODE)dt TMAT NE OH SME IS E%EIIPT7HENEFfiOMAND 7HE BA518 FOR THE ALLEOEO EXEMP• TpN.ANYVqL�TIONOFRECT10N7oat.68YANYAPPLICMITWHIIPEPMiT6U8JECTSTHEMPLICANTTO Z Re-Roof � ACMLFENALttOFNOTMORETWWFIVEMUNDRED00LLAHS(i60�.): OI,A40NMEROFTMEPAOPEirtY,ORGIYE1JPlDYEE9VATHW�0ESA51HEIR30LED]MPENSATCMd, � COTTBfCIaI WILL DO 7HE WORIC,NiD THE 6TRUC7URE IS FWT MIiENDfiOOR OFFERED FOH SILLE�SEC.70a1,BUSI� J � NESS AND PROFESSIONS CADE:TME CONTMCTONS UCENSE LAW OOES NOT APPLY TO/W OWNER OF = /IpPER�Y NM1iD YULDS OR MPR0IIES THEREOlL ANO WHO pOE9 9UCN WORN HIYSELiOR HERSELF ON � 7lGqU0H MS OR NEH ONM EMPLOYEES,PFOYIDED TNAT SUCN IMPROVEMEM9�RE NOt MEN�ED OF m GFFERm iORSAI.E G,YIOV�16VER iXE BLNLDINOOH RIPNOVEMIXf 44 BOLD WITMN ONE�E�NOF COMPIE TION,THE CMMER-0U0.DER WILL M+�VE TNE�UROEN OF PqOVMI�THAT ME OR SNE DI�NOT BINLD OR MPRDYE FOR 711E PURPOSE OF SALE1 � ❑I.JLSOVMEROF1HEiROPEHiY,MIfXCL116NELYCONTfUCTINOMIITHUCENSEUCON7MCTOH3 70 OONS7RUCT 7HE PRO.IECT(SEC.70u,lUSINE9S AND PROFESSIONB COOE:TNE COHTRACTORS LI- V81119�1OR ADJ.AREA CFNSE LAW DOES NOTMPLY TO AN OWNER OF A PROPEMY MRIDBU�LDB OR M1V1i0YES THENEON,AN� YMqCONTFACT6FOR8UCHOpO.1ECTSWITHACONTqACTOR�S�UCENSEDPUR9UANT7oTHECONTRAG QUANTITY DESCRIPTION FEE � TOf13 11GEN3E UW.} J O IAM O(EAIPT IA�DER 6EC. B.i V.C.FOR 7HI5 REASON q U ¢ �=' DATE OYVNER V � J � LICENSED CONTRACTOFS DECIJ�RATION W � 1 HEREBVAFFIRIA UNOEN PEHALTY OF PERlURY TMAT IAM UCENSED UNDER VROVISIONS OF CHApTER �(CpAMENCMIOWfTH5ECT10N70W�OFDM510N30FTHEBUSINE53ANDPROFE55KKJSCODE,AN� Z U 4YLICENSE i6 MI Ml FORCE AND EFFECT. m � LICENSE CLA53 �•�`� LIC.NORA��� � p�h 1-2$•Uo corrr J a = WORKERS'COMPENSATION DECLARATICN � � INERF,QYAFFIRMUNDERPENALTYDFPERIURYONEOFTHEFOILOWINGDECLARATIONS: U � Z k��W�YE AND Y/ILL WINTApV A CEHfIFICATE OF pON3ENT TO BELFaNSUHE FOR WOANERS' _ � TCOAd7ENSATqN,ASPRONDEDB`ISEC710N]7ooOFTHELA80RD00E.FOR7HEGERFORMMICE C� � pFTME WpWC i'OR WH1p1 THIS PER7A7IS ISSUEO. � 'F,i �_I HAVE ANO WRL MAIMNN WOILCERS'COMPENSATqN INSURANCE,A9 REOUIRED B1'&ECTION Q �7o00FrilEL�BORCOUE,FORTNEPEHWRMANCEOFTNFWORKFORWHICHTHISPERN1T15 � 169UED.MYMK7�K�RS' GENSAT�INSUMNCEGARRIFNAN�POLICYNUMBERARE: CONSTRUCT�ON y CARRIEA \ 1 �-- PLAN HEVIEVJ � pq,1GY NUMBER L,,,,A 1 �"L �4 1_1 -- ELECTRIC - ---_.�.. � (IHssEcnoraHE�MoreEaa6FlFrmoPnEPEH.arswaaNEM.ror+E000WuuR+�Maat.Fss1. PLUMBINQ L s :.._.:.J�' I CEIITIFY THATlI TFiE PERFOi1MANCE OF THE WaNK FOF WMICH 7H15 PERMR 1515SUE0,l MECHANICAL (� SFNLL NOT EMPLOY M!Y PEpSON W ANY MMINER SO AS M BECOME BUBJECT TCl THE /�!f (n WOpNERS'COMPENSATqNU1W50FGAL1fORNIqANDAClREE7f1ATIFl&WUlD9ECOME INSPECTIONFEE � BUBIECTTOTHEWOPKERS'CdAPENSA P(iONS10NSOF5ECTI0N87000F7NElABOR �SSUANCE ' �) � - _ CODE.I SHALLf W�R7MMIIh1001APLv E PROVISIDHS. -/'� DATE 1'����] APPLICANR��/'U`^+ l 1 t.. SMIP * • � WARNINCI:FAILUPE TO SECURE WONKERB'COMPENSATION COVERAOE IS UNLAWFUL,ANp 8MALL BE ENERGY P/C ."r� SUBJECTANEMPLOYEPTOCNIMINALPENALT�ESANDGVRFIMESUPTOONEHUNOREDTHOUSAND ENERGYPERMIT � pOLL�RS p1ao.OW).N 11DDITION TO THE COST OF COMOENSAiION,DAMAOES!13 PXOVIOE�FON IN � SECTION J70e OF 7HE IABOR CODE.INTERESL AND ATTORNEY'S FEES. q�'ENTION FEE: g CONSTRUCTION LENDINQ AGENCY PRE-ALT FEE: � IHEREBYAFFIRMUNOERPENALTYOFPEHJURYTHATINEREIS�CONSTRUCTIONLENDINOAOENCY WN TY�PERFDRMANCE OF 7T1E W�FiK FOR WHICH TNIS YEflMiT18ISSUED(SEG 90a�,qV.Q} � � LENDER'SNAME �S I,EN�ER'9AUDRE55 �^��^ W ICERTIFYTIU�TIWNEREA�7HISAPPUCqTqNANDSTATETHATTIEABOVEINFOflMAT10NI50DRRECL TOTAL FEES JJ � � � 1 A[3REE f0 Od1PLY WITH ALL CT'ANO COIINTY ORDINANCES AND 6TATE UWS REUITINU TO BUILDINO CONSTRUC'f10N,M1D HEREBY AU71qRIZE HEPRESENTATNES OF 7NIS COUNTY TO EMEP UPON iME S�. �BOVE•MENTIONEUP/qiER7YFORINSPEGTIONPURPO5E5. COMMENTS 9 � m PERM NAME(PiUHTI 4 � � ,�l (n �V N 81�NA R TTEE DAT � RECPL NO. 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